ACORE)
®CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDIYYYY) 3/19/2015THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
HNI
Risk Services
PO Box
510187
PO
New Berlin
WI
53151
CON JAC I NAME: FAX(A/C No, Ext): 262-782-3940 (A/C, No): 262-782-4198 E-MAIL
ADDRESS: certsAhni.com
INSURER(S) AFFORDING COVERAGE NAIC ti INSURER A : Great West Casualty Company
INSURED
JMB Express Trucking, LLC
1933 E Kelly Lane
Cudahy
WI
53110
INSURER B : INSURER C : INSURER D : INSURER E : INSURER F :COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE INDICATED. NOTWITHSTANDING ANY REQUIREMENT, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR TYPE OF INSURANCE ADDL INSR SUER WVD POLICY NUMBER (MM/DD/YYYY) POLICY EFF (MM/DD/YYYY) POLICY EXP LIMITS
A X
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
MCP03527C
04/01/2015 04/01/2016
EACH OCCURRENCE $ 1,000,000 $ 100 000 IJAMAUt 10 NtN i LU
PREMISES (Ea occurrence)
CLAIMS-MADE X OCCUR MED EXP (Any one person) $ 5 000
PERSONAL & ADV INJURY $ 1
000,000
GENERAL AGGREGATE $2,000,000
PRODUCTS - COMP/OP AGG $ 2.000,000$ GEN'L AGGREGATE PRO- LIMIT APPLIES X POLICY
n J
ECT PER: LOCA
X X AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS — X SCHEDULED AUTOS NON-OWNED AUTOSMCP03527C
04/01/201504/01/2016
COMBINED SINGLE LIMIT
jEa accident) $ 1.
000.000
BODILY INJURY (Per person) $BODILY INJURY (Per accident) $ PROPERIY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETEgf ON $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICE/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under
11FSCRiPTiON OF OPFRATICINS hpinw YIN
N/A
WC25939C
02/01/201502/01/2016
WC S1 Ai U- OTH- X
I
TORY LIMITS I ERE.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $
500,000
A Motor Truck Cargo
MCP03527C
04/01/201504/01/2016
Limit $100,000Deductible
$2,500
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)....--....—...— ...----
Sample Certificate
I
—
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
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AcoRti
CERTIFICATE OF LIABILITY INSURANCE
L.---
DATE (MWDD/YYYY) 1/27/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
HNI Risk Services
PO
Box 510187
New Berlin
WI
53151
CON IACT
NAME:
PHONE FAX
(A/C, No, Ext): 262-782-3940 (NC, No): 262-782-4198 E-MAIL
ADDRESS: certsahni.com
INSURER(S) AFFORDING COVERAGE NAIC
#
INSURER A : Great West Casualty CompanyINSURED
JMB Express Trucking, LLC
1933 E Kelly Lane
Cudahy
WI
53110
INSURER B: INSURER C : INSURER D : INSURER E : INSURER F :COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE INDICATED. NOTWITHSTANDING ANY REQUIREMENT, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR TYPE OF INSURANCE ADDL INSR SUBR VVVD POLICY NUMBER (MM/DDIYYYY) POLICY EFF (MM/DDfYYYY) POLICY EXP LIMITS
A
XGENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
MCP
03527
B
04/01/2014 04/01/2015
EACH OCCURRENCE $ 1,000,000
$ 100 000
I
F=NYErocc
Ni
ur
u
rence)
CLAIMS-MADE X OCCUR MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2.000.000 GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY n
7E-
p
I
LOC $A
X X — AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS — SCHEDULED AUTOS NON-OWNED AUTOSMCP03527B
04/01/201404/01/2015
COMBINED SINGLE LIMIT
(Ea accident) $ 1,000.000 BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $ PR E i DAMA E (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICE/MEMBER EXCLUDED? (Mandatory In NH)
If yes, describe under
DFSCRIPTIMI (iF CIPFRATHINS hpinw
YIN
NIA
WC25939C
02/01/201502/01/2016
IWC ST AI U- I OTH- TORY LIMITS ER
E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000
A Motor Truck Cargo
MCP03527B
04/01/201404/01/2015
Limit
$100,000
Deductible $2,500
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Sample Certificate
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
I
AUTHORIZED REPRESENTATIVE
—2
e<- . .
Social security number
or
Employer identification number
Form
W-9
(Rev. December 2014) Department of the Treasury Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the
IRS.Pr in t or ty p e See Sp ec ific Ins truc tions on p ag e 2.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
JMB Express trucking LLC
2 Business name/disregarded entity name, if different from above
JMB Express Trucking LLC
3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions certain entities, instructions Exempt payee Exemption code (if any) (Applies to accounts
(codes apply only to not individuals; see on page 3):
code (if any) II Individual/sole proprietor or . C Corporation
El
S Corporation III Partnership . Trust/estatesingle-member LLC
company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) LLC that is disregarded, do not check LLC; check the appropriate box in of the single-member owner.
/J• II Limited liability
Note. For a single-member the tax classification
❑ Other (see instructions)W
from FATCA reporting the line above for
maintained outside the U S.)
5 Address (number, street, and apt. or suite no.)
1933 E Kelly Lane
Requester's name and address (optional)
6 City, state, and ZIP code
Cudahy,WI 53110
7 List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for
guidelines on whose number to enter.
7
7
2
2
2
6
2
Part II
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.
Sign
Here
Signature of U.S. person ►General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:
• Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
Date ►
0/
7
2v/
-c-
• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.
By signing the filled-out form, you:
1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and
4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.
